Imane Bouasbia

METROPOLITAN
POLICE

PROFESSIONALISM HQ

Deputy Assistant Commissioner

Mr Graeme Irvine New Scotland Yard
Area Coroner for East London, Victoria Embankment

Walthamstow Coroner’s Court,

London
Queens Road,
Walthamstow, SW1A 2JL
E17 8QP
Email:
Tel: or 101
Your Ref: il

Our ref: Ps

Date: 30 December 2020

Dew Ma Ince,

| am the Deputy Assistant Commissioner for Professionalism within the Metropolitan Police
Service (MPS) and | am responding to your Regulation 28 Report to Prevent Future Deaths
dated 12'" November 2020 to the Commissioner of Police of the Metropolis. This followed the
conclusion of the Inquest into the death of Ms Imane Bouasbia on 3% January 2020 at Newbury
Park Station, London. The Inquest concluded on 22 September 2020.

You raise three matters of concern:

(1) The failure of officer 1 to effectively communicate to officer 2, either verbally or in
the CRIS handover, that Ms Bouasbia had expressed the view that she wished to
end her own life following the attack she sustained on 1*t January 2020.

(2) The failure of officer 2 to complete a risk assessment of Ms Bouasbia regarding
thoughts of self-harm or suicide.

(3) The police reaction to Ms Bouasbia’s Whatsapp text message at of 3 January
2020 indicating suicidal thoughts was limited to a non-expedited instruction on a
CAD action. The only response to Ms Bouasbia was a further Whatsapp text
message rather than a telephone call.

MPS response to matters of concern:

(1) The failure of officer 1 to effectively communicate to officer 2, either verbally or in
the CRIS handover, that Ms Bouasbia had expressed the view that she wished to
end her own life following the attack she sustained on 1% January 2020.

Ms Bouasbia referred to having suicidal thoughts in her initial telephone call to police and
these comments were recorded on the Computer Aided Despatch (CAD) report. Officer 1, who
responded to the CAD, was made aware of those comments before she met and spoke with
Ms Bouasbia. However, during their conversation officer 1 did not explore this any further as
on speaking with Ms Bouasbia the officer was satisfied that those thoughts were no longer
present and did not make specific reference to them when completing the report on the Crime
Reporting Investigation System (CRIS). However, officer 1 did provide the CAD reference
number in the CRIS report. Unfortunately, the sexual offences investigation team (SOIT)
officer (officer 2) did not review:the CAD report.

The MPS has a policy in place to address this area of concern; however, it would appear that
the policy was not adhered to at the time. The MPS General Investigation - Initial Investigation
Frontline Policy states; “Officers are to ensure the safeguarding of any person involved in the
investigation by assessing all victims/witnesses/suspects/persons in line with the Vulnerability
Assessment Framework (VAF)'. If deemed vulnerable, follow the policing response as per the
appropriate toolkit for adults and children. Complete a Missing Persons & Related Linked
Indices report (MERLIN) and flag appropriately on CRIS”.

The comments made by Ms Bouasbia when she initially reported her allegation to police,
should have identified her as being “vulnerable” and a MERLIN report should have been
completed and signposted on the CRIS report. While it is acknowledged that officer 1 did not
complete the MERLIN report, the SOIT officer could have still identified Ms Bouasbia’s
vulnerability from the CAD report and by ensuring that all police indices were checked prior to
contacting Ms Bouasbia. The SOIT officer should have completed this as part of the full risk
assessment at the outset of the investigation and Lg to making first contact with Ms
Bouasbia.

The MPS has introduced a THRIVE+ vulnerability assessment, which is currently being trialled
and is anticipated to be rolled out across the organisation in April 2021. Itis a set of principles
and a framework to assess the type of policing response or investigation required for a
particular set of circumstances. THRIVE covers: Threat — Harm — Risk — Investigation —
Vulnerability - Engagement + Prevention/Intervention. The framework is a tool that aligns to,
and enhances, the National Decision Model and includes the assessment and ongoing review
of risk during investigations. It also provides a common language around risk to improve
information sharing and decision-making.

This assessment tool will ensure officers consider and clearly document vulnerability on every
CRIS report, enabling a victim's vulnerability to be reviewed throughout the investigation. The
THRIVE+ risk assessment covers suicidal thoughts and vulnerability. The CAD operator
receiving the initial call would complete this assessment and determine what the response
grading of the call should be, for example, if the caller is considered to be extremely vulnerable
or suicidal then the CAD operator would endeavour to ay) on the call until police officers
arrive.

To immediately address the lessons learned prior to the full introduction of THRIVE+, on 18"
December 2020 an Operational Notice was published on the MPS internal website informing
all staff, including SOIT officers, that they must review all police indices, including the CAD,
prior to contact with the victim. Any identified vulnerabilities must be communicated to the
investigating officer or their supervisor and noted on the CRIS report. This will also be
addressed in future Continuous Professional Development days for all officers, commencing
in February 2021 for SOIT officers.

(2) The failure of officer 2 to complete a risk assessment of Ms Bouasbia regarding
thoughts of self-harm or suicide.

The MPS Rape and Serious Sexual Assault Policy Toolkit - Secondary Investigation, provides
details of the SOIT officer's role and responsibilities. This includes details regarding the
completion of a risk assessment with an additional risk assessment if the case is related to
domestic abuse. The SOIT officer on this occasion completed a partial risk assessment and
did not specifically cover vulnerability or record this.on the CRIS report.

A’SOIT officer completes a four-week training course to become qualified inthe role. The
course covers risk, but does not go into the detail around what documents should be reviewed
either before speaking to the victim or whilst the investigation is ongoing.

The MPS has introduced a newly enhanced SOIT risk assessment that specifically covers
suicide, cultural complexities and concerns around honour-based violence. It also mandates
that the SOIT officer review all police indices including the CAD. The new risk assessment is
mandatory for all SOIT officers to complete before speaking to a complainant and must be
recorded on the CRIS report and brought to the attention of a supervisor if there is anything
of concern.

The CAD report was restricted as per MPS instructions that state; “A CAD for Rape or sexual
offences should be restricted where the victim could be identified from the content of the
incident’. This would relate to most allegations of rape or sexual offences unless the caller
refuses to provide their name or address details, which is very rare. Other officers wishing to
review a restricted CAD would be required to contact MetCC or their local Operations Room
to gain access. It would appear that the SOIT officer was not aware of this process and
_ therefore this is now covered in the new SOIT risk assessment.

(3) The police reaction to Ms Bouasbia’s WhatsApp text message at of 3 January
2020 indicating suicidal thoughts was limited to a non-expedited instruction on a
CAD action. The only response to Ms Bouasbia was a further WhatsApp text
message rather than a telephone call.

The SOIT officer made the decision to return Ms Bouasbia’s message via WhatsApp as Ms
Bouasbia had been using WhatsApp as a method of contact between them. SOIT officers will
confirm with the victim the method of contact they would prefer when communicating during
an investigation. The SOIT officer is led by the victim’s preference of contact. The Victim's
Code also deems these methods as acceptable for communicating with the victim. However,
on this occasion, other methods of communication would have been preferable and had the
SOIT officer brought this to the attention of the investigating officer or the supervisor, advice
or guidance could have been provided on a better method of contacting Ms Bouasbia.

In the SOIT officer's WhatsApp text message to Ms Bouasbia, she suggested that she would
send officers to Ms Bouasbia’s home address to check on her welfare. Ms Bouasbia was not
in agreement with this, however, the SOIT officer decided to send a request for officers to
attend Ms Bouasbia’s address to check on her welfare. Unfortunately, the type of message
the SOIT officer sent attaches a response that requires an officer to be at the location within
48 hours. If the officer had contacted the MPS Control Rooms or their local Operations Room
direct, she could have explained the circumstances better and asked for a quicker check to
be conducted. As a result, the MPS did not allocate this call until some hours later despite
acknowledging the CAD message within 29 seconds of its creation.

Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by
telephone to speak directly with her. On 21% December 2020, the MPS addressed this by e-
mailing all SOIT officers and Public Protection Department managers with the instruction that
SOIT and investigating officers must inform a supervising officer if they receive any contact
from a victim that causes them concern. A course of action must be agreed and documented
on the CRIS report or CAD message and immediate contact made with the victim by
telephone. In addition, SOIT officers must ensure their work mobile telephone recorded
answer message provides alternative contact numbers should the SOIT officer be off duty or
uncontactable and the caller needs assistance.

From 2021, further Continuous Professional Development events for SOIT officers will include
suicide awareness and a contribution from a Hostage and Crisis negotiator regarding how to
more effectively engage with a person in a mental health crisis.

In conclusion

The MPS regrets that officers did not take appropriate action to identify Ms Bouasbia’s mental
health vulnerabilities and did not respond in an appropriate timely or effective manner to Ms
Bouasbia’s WhatsApp message of 3 January 2020.

The two officers involved have engaged in reflective practice with their respective supervisors
to ensure that the learning from this tragic event is reflected upon.

| hope that this response and action addresses the matters of concern you have raised. Please
do not hesitate to contact me should you have any further queries. ~

Yours sincerely,

Deputy Assistant Commissioner